La. Admin. Code tit. 37 § XIII-2507

Current through Register Vol. 50, No. 11, November 20, 2024

Section XIII-2507 - Qualifications of Auditors and Audit Coordinators

A. All persons performing billing audits, as well as persons functioning as provider audit coordinators, shall have appropriate knowledge, experience, and/or expertise in a number of areas of health care including, but not limited to, the following areas:

1. format and content of the health record as well as other forms of medical/clinical documentation;

2. generally accepted auditing principles and practices as they may apply to billing audits;

3. billing claims forms, including the UB-82 and UB 92, the HCFA 1500, and charging and billing procedures;

4. all state and federal regulations concerning the use, disclosure, and confidentiality of all patient records; and

5. specific critical care units, specialty areas, and/or ancillary units involved in a particular audit.

B. Providers or payers who encounter audit personnel who do not meet these qualifications shall immediately contact the auditor's firm or sponsoring party, but may not request information unrelated to the areas listed in §2507. A

C. Audit personnel shall be able to work with a variety of health care personnel and patients. They shall always conduct themselves in an acceptable, professional manner and adhere to ethical standards, confidentiality requirements, and objectivity. They shall completely document their findings and problems.

D. All unsupported or unbilled charges identified in the course of an audit must be documented in the audit report by the auditor. Individual audit personnel shall not be placed in a situation through their remuneration, benefits, contingency fees, or other instructions that would call their findings into question. In other words, compensation of audit personnel shall be structured so that it does not create any incentives to produce questionable audit findings. Providers or payers who encounter an individual who appears to be involved in a conflict of interest shall contact the appropriate management of the sponsoring organization.

La. Admin. Code tit. 37, § XIII-2507

Promulgated by the Department of Insurance, Office of the Commissioner, LR 20:311 (March 1994).

AUTHORITY NOTE: Promulgated in accordance with Act 664 of the 1993 Regular Legislative Session and R.S. 22:12.